Thursday, July 7, 2016

Reducing Failure-to-Wait Cesareans

A while ago, experts developed guidelines to help reduce "failure to progress" cesareans, called the Consensus for the Safe Prevention of the Primary Cesarean Delivery. Among other things, they changed the definition of active labor from 4 cm to 6 cm and encouraged providers to wait longer before resorting to a cesarean in order to reduce "arrest of dilation" cesareans.

But would these new guidelines actually translate into lower cesarean rates in real life? Here is a study at a single academic medical center which compared the cesarean rate in induced or augmented first-time moms before and after the guidelines were implemented. Would the new guidelines result in a meaningful decline in primary cesarean rates? Would outcomes be improved?

In a nutshell, yes, the cesarean rate was definitely lowered and outcomes improved. The cesarean rate in induced or augmented women dropped from 35.5% to 24.5%, and the overall cesarean rate dropped from 26.9% to 18.8%. And indeed, maternal morbidity was reduced.

Of course, because the new guidelines are very recent, the study size is limited. More research is needed to confirm that this change is helpful. But this study is very encouraging that indeed, many primary cesareans can be prevented with just a little bit more patience and time.

Now let's apply these lessons to the labors of "obese" women too. I would love to see a study that looked specifically at whether more time and patience in labor in high-BMI women could lower the rate of primary cesareans in this group too. My guess is that it would, since research shows that we tend to have longer first stages of labor and that care providers are often too quick to surgically intervene in the labors of high-BMI women. But wouldn't it be nice if we had research proving that more patience for women of size was helpful?


Obstet Gynecol. 2016 Jul;128(1):145-52. doi: 10.1097/AOG.0000000000001488. Reduction in the Cesarean Delivery Rate After Obstetric Care Consensus Guideline Implementation. Wilson-Leedy JG1, DiSilvestro AJ, Repke JT, Pauli JM. PMID: 27275806 DOI: 10.1097/AOG.0000000000001488
OBJECTIVE: To evaluate the rate of primary cesarean delivery after adopting labor management guidelines. METHODS: This is a before-after retrospective cohort study at a single academic center. This center adopted guidelines from the Consensus for the Prevention of the Primary Cesarean Delivery. Nulliparous women attempting vaginal delivery with viable, singleton, vertex fetuses were included. For the primary outcome of cesarean delivery rate among induced or augmented patients, 200 consecutive women managed before guideline adoption were compared with 200 similar patients afterward. Secondary outcomes of overall cesarean delivery rate, maternal morbidity, neonatal outcomes, and labor management practices were analyzed with inclusion of intervening spontaneously laboring women. RESULTS: Between September 13, 2013, and September 28, 2014, 275 women preguideline and 292 postguideline were identified to include 200 deliveries after induction or augmentation each. Among women delivering after induction or augmentation, the cesarean delivery rate decreased from 35.5% to 24.5% (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.38-0.91). The overall cesarean delivery rate decreased from 26.9% to 18.8% (adjusted OR 0.59, CI 0.38-0.92). Composite maternal morbidity was reduced (adjusted OR 0.66, CI 0.46-0.94). The frequency of cesarean delivery documenting arrest of dilation at less than 6 cm decreased from 7.1% to 1.1% postguideline (n=182 and 176 preguideline and postguideline, respectively, P=.006) with no change in other indications.  CONCLUSION: Postguideline, the cesarean delivery rate among nulliparous women attempting vaginal delivery was substantially reduced in association with decreased frequency in the diagnosis of arrest of dilation at less than 6 cm.

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